Glebe Fall 2017

Select age group:*

Child(ren) enrolled - click '+' to add siblings.*

Child's First Name	Child's Last Name	Child's Birth Date

dd/mm/yyyy

Parent first name*

Parent last name*

Home Phone*

Cell/Alternate Phone

Email*

NOTE: Hotmail addresses have been experiencing difficulties with receiving notifications. If you have another address you can use, it is recommended. Contact us for details.

Address*

Street AddressAddress Line 2CityProvincePostal Code

Caregiver Information

Full Name of Cargiver*

This is the person who will bring the child to class most often.

Caregiver's Relation to Child*

Emergency Contact Name*

If the caregiver had a medical emergency in the class, who should we call

Emergency Contact Phone*

Do you wish to be added to our mailing list to receive notifications about theme weeks, public shows, etc? You can unsubscribe at any time.'

Yes

I have read and understand the photo policy?*

Yes

PHOTO POLICY: You are welcome to take pictures of your child and the instructor at Monkey Rock Music classes, but please make an effort to exclude other children from your photos. Video is prohibited.

Please Select*

I authorize MRM to use our pictures
Please DO NOT use our pictures

During Monkey Rock Music classes, staff may take pictures of all adults and children for potential use in marketing materials, including but not limited to website, newsletters, print ads, etc. If you would prefer that you and your child's image not be used, please indicate below. Note that you and your child's picture may still be taken in class, but the image will be cropped or edited to ensure your wishes are respected.

How did you hear about us?

Other

Any questions/concerns about your enrollment?

Sub-Total

Price: -4,676 Quantity:

Discount

Price: 0

HST

Price: 0

Coupon

Total

0

Credit Card*

American Express

MasterCard

Visa

Card NumberExpiration Date Security CodeCardholder Name

Enrolment for: Glebe Fall 2017

Wednesdays - from Sep 13 to Dec 20 (15 weeks)

Instructor: Githmi

Caregiver Information